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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191202127
Report Date: 01/22/2020
Date Signed: 01/22/2020 01:26:23 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME:TEMPLE AHAVAT SHALOM EARLY CHILDHOOD EDUCATION CT.FACILITY NUMBER:
191202127
ADMINISTRATOR:TESSA CRAMERFACILITY TYPE:
850
ADDRESS:18200 RINALDI PLACETELEPHONE:
(818) 360-5183
CITY:NORTHRIDGESTATE: CAZIP CODE:
91326
CAPACITY:72CENSUS: DATE:
01/22/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Tessa CramerTIME COMPLETED:
01:00 PM
NARRATIVE
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On January 22, 2019 Licensing Program Analyst (LPA) LPA King conducted a follow up complaint investigation. Upon arrival, LPA met with Director, Tessa Cramer. During the investigation LPA discovered there were two incidents of Hand, Foot and Mouth (HFM) disease during the month in September 2019. The center did notify parents and the health department but did not notify Licensing department.

This Case Management consist of interviews with staff, and review of facility file and other relevant parties.

Based on interviews and physical evidence, it was determined staff failed to notify Licensing department regarding two or more children attending the center contracting the HFM disease in September 2019. The center is being cited for failure to submit unusual incident to Licensing department.

Exit interview was conducted, Appeal Rights, and a copy of this report was read and given to Director Tessa Cramer.

SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550

FACILITY NAME: TEMPLE AHAVAT SHALOM EARLY CHILDHOOD EDUCATION CT.
FACILITY NUMBER: 191202127
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/29/2020
Section Cited

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 Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the
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information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event. This requirement was not met as evidenced by: the center did not report unusual incident to the department ; which poses a potential health and safety risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2020
LIC809 (FAS) - (06/04)
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